Team Manager - AO Clinical Claims, Pooling

Job Description

The Team Manager is responsible for leading a team of USRN Clinical Claims Associates/Specialists supporting Accident & Occupational (AO) Clinical Claims operations. The role will drive operational excellence by ensuring achievement of client metrics, quality standards, service levels, productivity targets, compliance requirements, and employee engagement objectives.

The Team Manager will provide coaching, performance management, clinical guidance, and day-to-day operational leadership to ensure accurate claims processing and exceptional customer outcomes while maintaining regulatory and client standards.

Key Responsibilities

Operations Management

• Manage the daily operations of assigned clinical claims teams.
• Monitor and ensure achievement of productivity, quality, accuracy, compliance, and turnaround time targets.
• Analyze performance trends and implement action plans to address gaps.
• Ensure adherence to client processes, policies, and standard operating procedures.
• Support the achievement of account and business objectives.

People Leadership

• Lead, coach, and develop a team of Clinical Claims Associates/Specialists.
• Conduct regular performance reviews, coaching sessions, and career development discussions.
• Manage attendance, adherence, employee engagement, and retention initiatives.
• Create and maintain a high-performance culture focused on accountability and continuous improvement.
• Handle employee relations matters in partnership with HR and Operations leadership.

Quality & Compliance

• Ensure compliance with HIPAA, data privacy, client requirements, and regulatory standards.
• Conduct audits and reviews to ensure claims are processed accurately and consistently.
• Drive corrective and preventive action plans for identified performance gaps.
• Promote adherence to clinical documentation and claims adjudication standards.

Client Management

• Support Operations Leadership during business reviews and client discussions.
• Provide timely updates and insights regarding team performance.
• Participate in calibration sessions and process improvement initiatives.
• Maintain strong client relationships through consistent delivery of operational commitments.

Continuous Improvement

• Identify opportunities to improve workflows, productivity, and quality outcomes.
• Lead process improvement projects and change management initiatives.
• Drive knowledge-sharing and best-practice implementation across teams.

Qualifications

Minimum Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Bachelor's Degree in Nursing (BSN) or equivalent nursing qualification.
• Minimum 3-5 years of clinical nursing experience in a hospital, healthcare, insurance, disability claims, utilization review, case management, or related healthcare setting.
• Minimum 2 years of people management experience leading healthcare operations, clinical teams, BPO healthcare accounts, or claims operations.
• Strong understanding of medical terminology, clinical documentation, and healthcare processes.
• Excellent verbal and written English communication skills.
• Strong analytical, coaching, and stakeholder management skills.

Preferred Qualifications

• Experience in:
  • Disability Claims Management
  • Clinical Claims Review
  • Utilization Management
  • Case Management
  • Health Insurance Operations
  • Healthcare BPO Operations
• Experience managing US healthcare or insurance accounts.
• Lean Six Sigma, Quality, or Process Improvement certification is an advantage.
• Knowledge of HIPAA and healthcare compliance requirements.

Experience handling client-facing operational reviews and presentations.

Additional Information

Internal Qualifications:

• Must have Annual PDP score of Exceeds Expectations (4) or Outstanding (5)
• Tenure of at least 18 months on the current role
• No Active DA